Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy.

INTRODUCTION: Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue. METHODS: Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group. RESULTS: Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size. CONCLUSIONS: This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.

Poorly differentiated laryngeal neuroendocrine neoplasm with high serum calcitonin level, a case report, with literature review.

Neuroendocrine neoplasm (NEN) of the larynx consists of 0.6% of laryngeal cancer and is the second most common type after squamous cell carcinoma (SCC). Laryngeal NEN rarely secret calcitonin and should be differentiated from medullary thyroid carcinoma. It makes a diagnostic and therapeutic challenge. We describe a case of a laryngeal NEN with calcitonin hypersecretion. A 59-year-old man presented to our clinic with recurrent cough, dysphonia, hoarseness, cervical mass, and significant weight loss. Diagnostic workup showed a supraglottic mass. Biopsy of the lesion revealed large-cell neuroendocrine neoplasm. Further diagnostic workup showed elevated serum calcitonin level. The patient underwent total laryngectomy, thyroidectomy, and modified radical neck dissection. During his follow-up, new subcutaneous nodules appeared that were biopsy-proven metastases. Then adjuvant chemoradiotherapy was performed. Laryngeal NEN with hypersecretion of calcitonin is a rare entity. In patients with elevated serum calcitonin levels and head and neck tumors, it should be considered a differential diagnosis of medullary thyroid carcinoma. As the management and prognosis of these two neoplasms are entirely different.

A solitary precaval right renal artery: A case report.

Knowledge of aberrant renal vasculature is critical for preoperative planning of either open or minimally invasive renal surgery. A precaval right renal artery is a rare anatomical variant in which the artery passes anterior to the inferior vena cava(IVC), as opposed to coursing posteriorly. When encountered, this artery is mostly accessory and thus accompanied by renal vessels in orthotopic position. Here, we describe an unusual instance of a solitary, main precaval right renal artery. It can be diagnosed preoperatively by a cross-sectional imaging study. Awareness of this anomaly is very important to prevent iatrogenic injury during surgical intervention.

Fever of unknown origin as the first presentation of candida vertebral osteomyelitis: A case report.

Candida osteomyelitis is a rare disorder; however, its incidence has drastically risen especially during the last 3 decades. Diagnosis is usually delayed due to nonspecific symptoms. Thus, its management would not be performed at the proper time, which leads to increased morbidity. The optimal management of candida osteomyelitis is not clearly defined but most recommendations advise prolonged antifungal therapy in addition to surgery. Here, we report candida osteomyelitis in a patient with a history of pancreatic adenocarcinoma that presented with prolonged FUO as her first presentation. Fortunately, her symptoms completely resolved after prolonged medical therapy despite delay diagnosis due to her unusual presentation. To the best of our knowledge, it is the first report of candida vertebra osteomyelitis that presents with prolonged FUO as the first presentation.

Dieulafoy's disease of the bronchial tree: a case report / Doença de Dieulafoy da árvore brônquica: relato de caso

ABSTRACT CONTEXT: Dieulafoy's disease of the bronchial tree is a very rare condition. Few cases have been reported in the literature. It can be asymptomatic or manifest with massive hemoptysis. This disease should be considered among heavy smokers when recurrent massive hemoptysis is present amid otherwise normal findings. The treatment can be arterial embolization or surgical intervention. CASE REPORT: A 16-year-old girl was admitted to the emergency department due to hemoptysis with an unknown lesion in the bronchi. She had suffered massive hemoptysis and respiratory failure one week before admission. Fiberoptic bronchoscopy revealed a lesion in the bronchus of the right lower lobe, which was suspected to be a Dieulafoy lesion. Segmentectomy of the right lower lobe and excision of the lesion was carried out. The outcome for this patient was excellent. CONCLUSION: Dieulafoy's disease is a rare vascular anomaly and it is extremely rare in the bronchial tree. In bronchial Dieulafoy's disease, selective embolization has been suggested as a method for cessation of bleeding. Nevertheless, standard anatomical lung resection is a safe and curative alternative.

RESUMO CONTEXTO: A doença de Dieulafoy da árvore brônquica é uma condição muito rara, poucos casos foram descritos na literatura. Pode ser assintomática ou manifestar-se com hemoptise maciça. Esta doença deve ser considerada em fumadores pesados quando eles têm recorrentes hemoptises maciças sem outros achados anormais. O tratamento pode ser tanto embolização arterial como intervenção cirúrgica. RELATO DE CASO: Uma menina de 16 anos foi admitida no Serviço de Urgências devido a hemoptise com uma lesão nos brônquios de origem desconhecida. Havia sofrido hemoptise maciça e insuficiência respiratória uma semana antes da admissão. A broncoscopia de fibra óptica relevou lesão no brônquio do lobo inferior direito, com suspeita de ser lesão de Dieulafoy. Foi realizada uma segmentectomia do lobo inferior direito com excisão da lesão. O resultado da paciente foi excelente. CONCLUSÃO: A doença de Dieulafoy é uma anomalia vascular rara, sendo extremamente rara na árvore brônquica. Na doença de Dieulafoy bronquial, embolização seletiva tem sido sugerida como método para cessação do sangramento; no entanto, a habitual resseção anatômica do pulmão é uma alternativa segura e curativa.

Dieulafoy's disease of the bronchial tree: a case report.

CONTEXT:: Dieulafoy's disease of the bronchial tree is a very rare condition. Few cases have been reported in the literature. It can be asymptomatic or manifest with massive hemoptysis. This disease should be considered among heavy smokers when recurrent massive hemoptysis is present amid otherwise normal findings. The treatment can be arterial embolization or surgical intervention. CASE REPORT:: A 16-year-old girl was admitted to the emergency department due to hemoptysis with an unknown lesion in the bronchi. She had suffered massive hemoptysis and respiratory failure one week before admission. Fiberoptic bronchoscopy revealed a lesion in the bronchus of the right lower lobe, which was suspected to be a Dieulafoy lesion. Segmentectomy of the right lower lobe and excision of the lesion was carried out. The outcome for this patient was excellent. CONCLUSION:: Dieulafoy's disease is a rare vascular anomaly and it is extremely rare in the bronchial tree. In bronchial Dieulafoy's disease, selective embolization has been suggested as a method for cessation of bleeding. Nevertheless, standard anatomical lung resection is a safe and curative alternative.